Bipolar Disorder Uncovered

This ebook guide teaches you how to keep your symptoms of bipolar disorder under control and have a manageable, excellent life even with bipolar symptoms. You will be able to stop engaging in destructive behavior, get your emotions under control, and handle stress in the way that you usually envy everyone else doing. It is not fair that you are afflicted with this; bipolar disorder is under-diagnosed and tends to affect your live and lives of those you love in a powerful, often negative way. You can put that behind you now. You no longer have to live that way. This ebook guide teaches you how to tell your negative symptoms to take a hike, and MAKE them do so. You do not have to feel guilt over your disorder. You cannot help it. But now, we can help you control it, and manage your symptoms so you can have the normal life you deserve. Read more...

Bipolar disorder can be conceptualized as a continuum or spectrum of mood disorders.9 They include four subtypes bipolar I (periods of major depressive, manic, and or mixed episodes) bipolar II (periods of major depression and hypomania) cyclothymic disorder (periods of hypomanic episodes and depressive episodes that do not meet all criteria for diagnosis of a major depressive episode), and bipolar disorder NOS. The defining feature of bipolar disorders is one or more manic or hypomanic episodes in addition to depressive episodes that are not caused by a medical condition, substance abuse, or other psychiatric disorder.1

Weissman and collaborators (1996) estimated the rates and patterns of bipolar disorder based on population-based studies that had used similar methodology. Studies from 10 different countries (United States, Canada, Puerto Rico, France, West Germany, Italy, Lebanon, Taiwan, South Korea, and New Zealand) were included. Lifetime prevalence rates for bipolar disorder were consistent among countries. The lowest rate was found in Taiwan (0.3 per 100) and the highest in New Zealand (1.5 per 100). Gender ratios did not differ across countries. Due to the relatively small sample size, risk factors were not explored.

The ECA study (Regier et al., 1990) reported that the Bipolar I group had a prevalence of substance abuse of 60.7 . The ECA investigators suggested that a high degree of comorbidity in bipolar disorders greatly complicates treatment. Interestingly, the ECA Study (Helzer and Pryzbeck, 1988) reported that the prevalence of comorbid alcoholism in mania was three times that in major depression. Furthermore, the likelihood (odds ratio) of an individual with bipolar disorder having a substance use disorder was 6.6 times greater than that of the general population. The only diagnosis that had a higher ratio than mania was antisocial personality disorder. Tohen et al. (2000) found in a treatment-based sample that the comorbidiy of substance use disorder in a cohort of first episode mania patient to be 17.3 . This finding suggests that in most cases the sequence of comorbid substance use disorder appears after the onset of bipolar disorder. Comorbidiy of anxiety disorder has also been found to...

Patient's history and symptomatology, may prove helpful. The Mood Disorder Questionnaire (MDQ) is a tool that combines DSM-IV criteria and clinical experience to screen for bipolar disorder in primary care settings (Hirschfeld et al., 2000). It is a brief, 1-page self-report questionnaire with 13 yes no items and two additional questions regarding functioning and timing of mood symptoms, and typically can be completed in 5 minutes or less. Seven or more positive responses to questions about manic symptoms, plus positive responses to the severity of impairment (moderate or severe) and coincident timing of symptoms yields a positive screen. Specificity and sensitivity of the MDQ vary widely by clinical setting, having the best combination of the two when given to patients with suspected mood symptoms (93 specificity 58 sensitivity) but performs more poorly in general community samples (97 specificity 28 sensitivity) (Hirschfeld et al., 2003 Hirschfeld et al., 2005). Other screening...

Stacy, 38, had two young daughters and worked part time for an accounting firm. She had carried the bipolar I diagnosis for at least 15 years and took Depakote on a regular basis. Although she agreed that she'd had severe mood swings, her interpretations of their causes tended toward the psychological rather than the biological. She often doubted that she had bipolar disorder She was scientifically trained and felt that the absence of a definitive biological test meant that the diagnosis should remain in doubt. Her psychiatrist frequently reminded her of her family history Her uncle had been diagnosed with bipolar illness and alcoholism, and her mother suffered from major periods of depression. But she remained unconvinced and continued to wonder whether she really needed medication. After all, she had been feeling fine for more than a year. She toyed with the idea of discontinuing her Depakote but was talked out of it, time and time again, by her psychiatrist. Two major questions...

A controversial DSM-IV criterion (APA, 1994) is that manic episodes precipitated by somatic antidepressant treatment such as electroconvulsive therapy or medication are not considered part of a Bipolar I disorder but instead would be classified as substance induced mood disorder. DSM-IV includes specific criteria for hypomanic episodes and for cyclothymic disorder. A cyclothymic disorder is characterized by hypomanic episodes interspersed with mild symptoms of depression. In addition, DSM-IV provides criteria for subtypes of Bipolar I disorder, including the single manic episode where there should be the presence of only one manic episode and no past major depressive episodes. It also includes bipolar disorder not otherwise specified (NOS) examples include a history of recurrent hypomanic episodes without any recurrent depressive symptoms or manic episodes superimposed on psychotic disorder NOS, residual schizophrenia, or a delusional disorder. DSM-IV also includes the category mood...

Depression and Bipolar Support Alliance (800-826-3632 www.dbsalliance.org) is devoted to educating consumers and their family members about mood disorders, decreasing the public stigma of these illnesses, fostering sell-help, advocating for research funding, and improving access to care. You can fill out a confidential on-line mood disorder screening questionnaire to help you identify whether you have the signs of bipolar disorder, Positive results front this questionnaire suggest that a more comprehensive mental health evaluation may be necessary. National Alliance for the Mentally 111 (800-950-NAMI www.nami.org) is a grass roots, self-help, support and advocacy organization for people with severe mental illnesses (including bipolar disorder, recurrent depression, and schizophrenia), their family members, and friends. Child and Adolescent Bipolar Foundation (847-256-8525 www.bpkids.org), a parent-led organization, provides information and support to family members, health-care...

People often have mistaken beliefs about alcohol, drug substances, and bipolar disorder. Some of these are listed in the sidebar on this page. I've heard people with bipolar disorder claim that marijuana or cocaine is just as effective as a mood stabilizer such as Depakote in controlling their mood states. They argue that alcohol calms them down, or reduces their anxiety, or improves their depression they argue that marijuana boosts their mood when they are depressed. One patient said, For me, alcohol is like the ropes that keep the hot air balloon from going up . and on the other side is like a disguise covering over the depression. Some people do drink or use drugs to make themselves feel better, but whether these substances are really doing the trick as opposed to making their moods worse is another question. We know that alcohol worsens depression (as in the examples given above). People who have both bipolar disorder and alcohol problems also have more rapid cycling, mixed...

Louise was on the verge of quitting her job when she decided to have an open conversation about her bipolar disorder with one of the partners in the law firm, a woman who, she felt, had been on her side. Louise apologized for her irritability and explained that she needed more consistent work hours, adding that the unpleasant tasks she had been assigned in the morning were better off assigned to the afternoon. The law partner was unwilling to compromise on the amount of work assigned to Louise or the quality she expected. But given that Louise was a valued employee, the partner did compromise on some other issues limiting the number of late nights she would have to work, allowing her to do some of her work at home, and deferring the unpleasant tasks until later in the day. These adjustments made a great deal of difference to Louise. She eventually decided to cut to a half-time work week, which was much better for her from the standpoint of mood stability. If you have a bipolar...

This is the presence of either a manic episode or hypomania. A manic episode is a period of expansive or irritable mood, lasting at least 1 week with three or more of the following symptoms grandiosity excessive energy, and diminished need for sleep talking more and faster than usual racing thoughts and flight of ideas distractibility increase in goal-directed behavior and high-risk activities such as overspending or bad judgment in business or sex. Hypomania is a distinct period of at least 4 days of expansive or irritable mood during which the client feels exceptionally well or cheerful and, when accompanied by cycles of depression, can signify a less severe form of bipolar disorder.

Some of the strongest statistical findings and conceptual arguments regarding the relationships between categories of mental disorder and kinds of creativity concern the bipolar mood disorders. Empirical research in this area started in earnest with the path-breaking work of Dr Nancy Andreasen, who studied creative writers who had attended the Iowa Writers' Workshop and found higher rates of affective disorders and symptoms in writers and their relatives than in control individuals. Dr Kay Jamison, who did extensive work emphasizing writers and composers, also documented an alarmingly high rate of suicide in these populations, something others found in abstract expressionist artists. She has also written a beautiful autobiographical account of life with bipolar disorder in An Unquiet Mind.

Then Tegretol, or the newer anticonvulsant, Topamax, may be alternatives for you. New drugs for bipolar disorder are being developed ail of the time, and it may be that easily tolerated medications that work just as well as the Big Three will eventually become available. Many people feel that taking medication is a sign of personal weakness. It feels like admitting that you're sick, defective, or mentally ill. Certainly, taking medication daily can remind you of your troubles and make you resent the illness even more than you do already. But many people take this perspective further and claim that they can get along without medication just by exerting self-control. If you are in a hypomanic phase, you're particularly likely to feel this way. Unfortunately, bipolar disorder cannot be controlled by sheer willpower. Neither can other biologically based illnesses. Bipolar disorder carries the stigma of mental illness, and taking medication can become a proxy for this stigma. You may worry...

Amy, age 33, had a six-year history of bipolar disorder. Three years after being diagnosed, she began a period of rapid cycling that seemed to be provoked, in part, by an on-again, off-again relationship with her boyfriend. When she abruptly relocated out-of-state due to his business, her rapid cycling intensified. She obtained part-time work in her new city and sought psychiatric treatment. Her psychiatrist gave her a combination of lithium and Depakote, which helped even out her cycles, but she still experienced unpleasant ups and downs. Her sleep was quite variable from night to night. What does it mean to manage bipolar disorder successfully In Chapter 5 we talked about the risk factors in bipolar disorder (things that make your illness worse). There are also protective factors things that keep you well when you are vulnerable to mood swings. You are already familiar with some of these protective factors from earlier chapters for example, consistency with medication and having...

Many people with bipolar disorder never need to be hospitalized. In addition, alternatives to inpatient hospitalization such as partial hospital or day hospital programs have emerged in recent years as short-term strategies for emergencies. These programs provide close monitoring of your symptoms and treatment response without the need to enter an inpatient facility. But if your manic symptoms escalate to a certain point of disruptiveness, or if you are actively suicidal or dangerous to others, there is a good chance that your doctor will recommend that you be hospitalized for a period of time. You are more likely to be hospitalized if you are manic (or mixed) than if you are hypomanic or depressed.

Depression comes and goes in different ways for different people. Here I talk about two types of depressive onset as experienced by people with bipolar disorder. It is helpful to know that for some people, depressive onsets are dramatic, whereas for others, the onsets are subtle. If your onsets are subtle, it may not always be clear to you (or your significant others) whether your depression is a new episode or the continuation of an existing one. With experience, you may be able to distinguish minor differences over time in the severity of your depressed mood or your energy and activity levels.

There is virtually no research literature on what kinds of jobs are best for people with bipolar disorder. We suspect that people with the disorder should avoid jobs that involve sudden bursts of social stimulation with little down time in between (for example, being a waitress at a bar with a happy hour), frequent travel across time zones, or consistently stressful interactions with others (for example, working in a hospital emergency room). We also suspect that people with the disorder do better with constant work hours and predictable workdays than in jobs requiring shifting schedules (for example, working on weekdays one week and then weekends the next, or working evening shifts followed immediately by morning ones). Jobs in restaurants, manufacturing, nursing, and retail sales often require variable shifts, whereas jobs in accounting, computer programming, banking, and schools are usually more consistent. But if the jobs in the former category appeal to you, you may not have to...

Robert has continued to have mood cycles, but his episodes increasingly resemble hypomanias rather than manias. He feels he has a good relationship with Dr. Barnard and his psychologist, and he and Jessie are still together and working on their problems. He has explained his bipolar disorder to his son, who, with time, is becoming more understanding.

Notice that in describing these course patterns, I don't refer to depression as a change from normal mood. In my experience, people with bipolar disorder do not ever feel like they get to a state of normal mood. In fact, they feel that their moods are always fluctuating. Many say that they are always somewhat depressed. Of course, it's not entirely clear what normal mood means for the typical person some people seem to feel fine most of the time, whereas others are always somewhat anxious, angry, bored, disappointed, or sad.

How important is it to know when you are getting manic One study indicated that there were two predictors of rehospitalization in bipolar disorder not taking medications, and failing to recognize the early signs of relapse (Joyce, 1985). On a more hopeful note, people with bipolar disorder who receive educational interventions, such as learning to identify early warning signs of mania and then seeking mental health services, are less likely to have full recurrences of mania and have better social and work functioning over 18 months than those who do not receive this kind of education (Perry et ah, 1999). As Robert said, once he and Jessie had begun to implement a successful relapse prevention plan, I used to think I was in the driver's seat when I was manic, but that was just the illness talking. Now I think I'm in the driver's seat when 1 can stop myself from getting manic. In this chapter, you'll learn a three-step strategy for getting off the train before mania takes you for a...

So far, the cognitive restructuring method I've described could apply to almost any form of depression or anxiety. The method applies well to bipolar disorder, but bipolar depressions tend to be much more severe than those experienced by people going through life transitions. So, in constructing your alternative or balanced thoughts, consider the role of your disorder particularly, its biological and genetic underpinnings in modulating your view of the causes of negative events. Do chemical imbalances of the nervous system explain your behavior in certain situations better than character flaws Could your emotional reactions in the heat of the moment have been due to your disorder rather than your inability to deal with people Katrina worried that I'm too emotionally unstable to be a consistent figure in their (her students') eyes. Indeed, negative interactions with her students probably had a more powerful effect on her mood states than might be the case for a person without bipolar...

Randy, a 45-year-old plumber, had two episodes of depression and several hypomanic episodes. His most recent episode, a depression, led to the loss of his job. His wife, Cindy, had a rudimentary understanding of bipolar disorder but was fairly intolerant of his apparent inability to function. She frequently spoke to him in derogatory psychiatric lingo That's your mania talking Last night when we got into that argument, you were totally rapid cycling You're doing your ADD attention deficit disorder thing again. In marital sessions, however, Cindy revealed that she really didn't believe his mood problems were of a biological origin. She blamed them on his crazy, dysfunctional family, his temperamental nature, and unconscious, unresolved stuff with me. She also wasn't convinced by the genetic evidence that Randy's father had had bipolar disorder.

N Chapter 3 we discussed the rather dry (though useful) DSM-IV diagnostic criteria. What these criteria do not address or convey is the emotional impact of learning you have bipolar disorder and acknowledging its reality. Most of my patients go through painful struggles in coming to terms with this diagnosis. Initially, they experience anger, fear, sadness, guilt, disappointment, and hopelessness. These are not manic-depressive cycles but rather a process of forming a new sense of who they are, a new self-image that incorporates having biological imbalances that affect their moods. It may sound like I'm talking about people who have had only one or two manic or depressed episodes and are surprised by the diagnosis, but I've also seen these reactions in people who have been hospitalized for the disorder numerous times. What's Unique about Bipolar Disorder People who have to live with medical diagnoses such as diabetes or hypertension go through similar emotions in coping with their...

Another person with bipolar disorder, Katrina, age 41, had emigrated to the United States from Hungary. A year after arriving she obtained a job at an inner city school teaching teenagers who were developmentally disabled. During a particularly difficult day, three of the boys in the class cursed at her and told her she was the worst teacher they'd ever had. By day's end, she felt quite depressed and anxious, and didn't want to go back to work. She took two days off, citing mental exhaustion. She recounted thoughts in reaction to this event, such as, Maybe I shouldn't be a teacher . 1 don't know if 1 have the strength and willpower . . . I'm not effective I can't deal with it by myself . . 1 don't belong 1 can't make it. She identified I'm not effective as the most powerful, emotion-provoking hot thought.

Robert, the man discussed at the beginning of the chapter, reported feeling very sexual and having racing thoughts before he had changes in his mood. His girlfriend Jessie saw it differently She thought he became irritable first, then loud and physically intrusive. Another person with bipolar disorder, Tom, said that his manias almost always involved religious preoccupations and paranoia. His parents described him as getting a certain look in his eyes and muttering stuff underneath his breath. The physician who treated Alan, the 60-year-old refrigerator repairman who believed that others could hear what he was thinking, felt that Alan's bouncy, upbeat quality was his first prodromal sign. Characterizations like these are helpful in rounding out what your prodromal phases look like from your own vantage point and the vantage point of others.

The Diagnosis and Course of Bipolar Disorder To understand the symptoms, diagnosis, and causes of your bipolar disorder quite angry and drove to the casino to pick her up, He arrived at the agreed-upon place and time, only to find that Martha was not there, so he returned home where he found his wife, disheveled, sleep deprived, and angry. After sobbing for several hours, she finally agreed to go with him to be evaluated at a local hospital. She was admitted to the inpatient unit and given a diagnosis of bipolar disorder, manic phase. Bipolar disorder is a mood disorder that affects at least one in every 70 people and puts them at high risk for the kinds of problems in their family, social, and work lives that Martha suffered. People with bipolar disorder are also at high risk for physical problems, alcohol and substance use disorders, and even suicide. Fortunately, there is much hope. With medications, psychotherapy, and self-management techniques, it's possible to control the rapid...

People with bipolar and other depressive disorders often feel hopeless, as if nothing will ever change for the better. They feel a strong need for relief from ''psychic pain colored by the fear and anticipation of increasing, uncontrollable, interminable pain (Fawcett et al., 2000, p. 147). Some people honestly want to die. But in my experience, most people with bipolar disorder want relief from the intolerable life circumstances and the emotional, mental, and physical pain that goes along with depression and anxiety. When your depression is spiraling downward and you feel a sense of dread and apprehension, you may desperately want to live, but suicide can feel like the only escape from your intolerable feelings. ium decreases suicide attempts and completions by people with bipolar disorder (Baldessarini et al., 1999 Tondo &amp Baldessarini, 2000 Simpson &amp Jamison, 1999). The antidepressant, anticonvulsant, and antipsychotic drugs decrease the agitation and aggressiveness that can...

Consider the data for the randomized prospective study of the effect of lithium on manic depression in males given in Tables 2 and 5. Let p1 denote the probability (or risk) that a male patient with manic depression (selected from the same population as the study sample) treated with lithium will have an episode within 3 months, and let p2 denote the probability that a male patient with manic depression given the placebo will have an episode within 3 months. Since p1 0.27 of the lithium patients had episodes within 3 months compared with p 0.7 of the placebo patients (see Table 5), we estimate p1 and p2 to be 0.27 and 0.7, respectively. Often it is of interest to compare the degree of association between two dichotomous variables for different populations. For example, suppose that data similar to the lithium study data given in Table 3 for male patients with manic depression have been collected for placebo and lithium groups of female patients with manic depression. Furthermore,...

Consider the data for the study of the effect of lithium on manic depression in males given in Table 2. In Table 9 are hypothetical data collected for females with manic depression. Example 3. For the data for the randomized study of the effect of lithium on manic-depression in males and females given in Tables 2 and 9 (1) estimate the gender-specific odds ratios (2) test if the gender-specific odds ratios are equal using the Breslow - Day test (3) test the null hypothesis of no association, controlling for gender, using the Mantel - Haenszel test (4) estimate a weighted average of the odds ratios using the Mantel - Haenszel estimate and WLogit and (5) give 95 confidence intervals for the weighted average of the odds ratios. In Table 11 is a partial output from a SAS analysis of these data. Pertinent results are indicated in bold. Interpretation We estimate that the odds of a male with manic depression on lithium having an episode within 3 months are 16 of the odds for a male with...

Interpretation We estimate that the odds of a patient with manic depression on lithium having an episode within 3 months is 18 of the odds of a patient with manic depression in the control group having an episode, controlling for gender. 5. Computations for a 95 confidence interval using Equation 6 Interpretation We have 95 confidence that the odds of having an episode within 3 months for a lithium patient with manic depression is between 10 and 32 of the odds for a control patient with manic depression, controlling for gender.

Ideally, a family study should use the blind case-control paradigm, a staple of epidemiology and behavioral science. The cases and controls used in genetic studies are known as probands. We usually select probands with the disorder from a source that is enriched with the diagnosis of interest. For example, patients in psychiatric clinics are more likely to have bipolar disorder than patients in a family practice clinic. Furthermore, patients in a bipolar specialty clinic are more likely to have bipolar disorder than patients in a general psychiatric clinic. Mendlewicz et al. (1975) examined the accuracy of the family history method in the context of a family study of mood disorders. The probands were 140 patients with either bipolar disorder or major depressive disorder. When the probands were used as informants for the family history method, the rates of mood disorders in the family were underestimated. The family history method was most accurate when the...

Lack of Statistical Independence Among Family Members. When comparing a group of relatives of bipolar patients with relatives of normal controls on the presence or absence of bipolar disorder, one of the many statistics available for assessing association in a 2 X 2 contingency table would seem to be suitable. The rows of the table would be formed by the probands diagnosis (bipolar or not) and the columns by the relatives diagnosis (bipolar or not). This would be fine if we had sampled only one relative from each family.

Traditionally, there are two broad classes of mood disorders major depression and bipolar disorder, estimated by some studies to affect roughly 5-10 and 1 of the population, respectively. Even here, though, there are further spectra, which range into milder variants. The underlying risk for mood disorders displays a strong genetic influence, as shown by the results of adoption and twin studies. However, there is also a large (but poorly understood) environmental component. Bipolar risk or liability involves a more marked genetic component than does risk for unipolar depression. The strong tendency for bipolar mood disorders to run in families is illustrated by one study of over 500 relatives of bipolar disordered (manic-depressive) individuals, in which over 23 of the relatives had a major mood disorder. Even though these relatives were chosen because they had a family member with bipolar disorder, over half of all the mood disorders in these relatives were unipolar depression rather...

At this time, research is more plentiful on creativity in families with bipolar compared to unipolar disorders. It is worth repeating that pure unipolar depression is an even more common outcome in individuals with a bipolar family history than are bipolar mood swings, and that such depression may also predict for creativity. One preliminary study suggests, for example, that creativity may be higher in depressed patients with bipolar disorder in their family than in depressed patients without this family history. Perhaps there are subtle and subclinical factors operating - even ones that are adaptive and positive - beyond the more debilitating symptoms. This issue needs careful study. Clinicians can be so intent on sniffing out psychiatric illness and dysfunction that they fail to notice when something is going right, such as unusual creativity.

Several modern studies of artistic creativity and mood disorders are notable because they provided more solid support to a range of older and less rigorous studies that pointed in the same direction. For example, in Nancy Andreasen's study of 30 well-known creative writers who were teaching at the renowned Iowa Writers Workshop, a remarkable 80 had a history of a major mood disorder (compared to 30 of controls). In addition, over half of those affected had a form of bipolar disorder, and a little over half of that number had a history of a bipolar II disorder, showing milder mood elevations.

More subtle bipolar disorders and family history were not assessed. Still, where overt mood disorders are concerned, the best predictor is not being an eminent creative person but, rather, an eminent creative artist. Note, however, that there are many mood-disordered people who do not become eminent, or even highly creative. What other factors might combine to make the achievement of eminence in Western culture more likely An experiment by DePetrillo and Winner found that doing creative artwork elevated self-reported mood in college students in whom low mood had been induced by exposure to videos showing distressing scenes. By contrast, simply copying abstract designs or solving challenging verbal puzzles did not elevate mood significantly. The mood-elevating effects of creative artmaking may make artistic endeavors especially attractive to individuals with mood disorders this may help explain the over-representation of individuals with mood disorders among creative artists.

Strong motivation is important for creativity, especially for the creator with a bipolar disorder. Ruth Richards and Dennis Kinney have shown a definite preference for work-related over leisure-related creativity among bipolar subjects in a sample of everyday creators. (By contrast, other research by Kinney, Richards, and colleagues found that individuals with schizotypal personality traits, which are elevated in relatives of schizophrenia patients, showed greater preference for leisure-related creativity.) A number of personality factors linked with bipolar mood disorders have been proposed that may raise the chance of eminent recognition when creative talent is already present. These factors include a driven work orientation, an ability to think in broad and ambitious terms, altruistic and socially concerned motives that may accompany mood elevation, a sense of 'standing apart' from the mainstream, and a need for external validation.

The phenomenon of compensatory advantage may be relevant to creative ability. In sickle cell anemia, inheritance of the same recessive mutant gene from both parents leads to serious and often fatal medical disease. By contrast, inheritance of only one copy of the mutant gene (i.e., carrier state) may often result in only a mild anemia, while providing a compensatory advantage of resistance to malaria. In the case of some psychiatric illnesses such as bipolar disorder, while the genetic model may be more complex, it seems plausible that certain genes that increase risk for the disorder may also carry a compensatory advantage involving increased creative potential. The numbers of people affected is important millions of people are affected by mood disorders, so that the benefit of increased creativity would affect not just the achievements of a handful of highly eminent people, but the everyday lives of millions of individuals. This phenomenon may also involve a more complex variant of...

Unipolar patients have reported a heightened sensitivity when depressed. They do not, however, necessarily report advantages ascribed by bipolar subjects to elevated mood states. Despite preliminary evidence that people with a history of depression may show higher everyday creativity if they have a family history of bipolar disorders, one cannot necessarily conclude that it is the episodes of the depression themselves that are conducive to creativity. Rather, it may be associated with sub-clinical hypomanic highs related to a family history of bipolar disorder.

Bipolars, and in depressed individuals with a bipolar family history, and it suggests operation of some subtle cognitive factors associated with the liability for bipolar disorder. In fact, there are particular qualitative patterns of unusual thinking that differentiate mania from schizophrenia, patterns that might yield higher creative potential in the former. For bipolar disorders, this involves combinatory thinking, with incongruous combinations of ideas and playful confabulation, as described in Philip Holzman and Mary Hollis Johnston's Thought Disorder Index. These patterns involve loosely tied together ideas and often have a playful quality to their production. These styles produce novel combinations of ideas and unconventional perspectives that may be valuable in generating innovative solutions to problems that would not occur to other people.

In October 1996, an invitational conference in New York, on Manic-Depressive Illness Evolutionary and Ethical Issues, was convened by Kay Jamison of Johns Hopkins and Robert Cook-Deegan of the National Academy of Sciences. Participants came from around the world to discuss the genetic and environmental factors, social costs, and adaptive value of bipolar disorder. The participants, who included distinguished scientists and clinicians, urged caution, in this burgeoning era of genetic engineering, against any precipitous efforts to remove from the population gene(s) that increase liability for bipolar disorder, given that this liability is complex, not fully understood, and may have creative advantages for individuals and society.

There is support for links between creativity and bipolar and unipolar mood disorders, and perhaps more importantly, with psychiatric family history and the underlying risk one carries, which might manifest in different ways. The manifestations of this risk differ in nature and intensity between eminent and everyday creators. For eminent creators, there is a high prevalence of mood disorders in the arts in particular, especially of bipolar disorders. Mild mood elevation seems particularly conducive to creative insight, potentially offering cognitive, affective, and motivational advantages. Outside of the arts, major mood disorders are less common, although more information is needed about mild or subtle mood swings or possible family psychiatric history. Perhaps aspects of a familial liability to bipolar disorder also help influence a drive toward eminence.

Regarding personal or family history of bipolar disorders, the following points are partly supported and worthy of further study. Some individuals may be more apt to (a) stand apart from the mainstream, due to differences that include identified illness and its effect (b) come up with new ideas as a behavioral norm, as well as to challenge old ones, and to do so often in the world of work and social contributions (c) be more aware at times of what is going on in their immediate environment or in the world (d) be more sensitively attuned to input in general (e) for a subset of people, be more willing and able to face certain adversities head on, as per the model of acquired immunity and (f) at times be more altruistically inclined in their creative intentions.

The evolutionary hypothesis - that the spectrum of bipolar disorders (including unipolar disorder where there is a family history of bipolar disorders) have been favored through evolution - could draw on multiple advantages, as related to a reproductive advantage. With compensatory advantage, a genetically influenced advantage may relate to, and in evolutionary terms compensate for, the morbidity of mood disorders. With acquired immunity, the creative twig may be bent in a positive way for later personal resilience and creative coping.

Generally speaking, social involvements of all sorts are associated with positive mental health. A huge literature, for example, indicates that married people have less distress than unmarried people (Mirowsky &amp Ross, 2003). The greater social integration married people gain through more supportive relationships and ties to community institutions largely account for this relationship (Umberson &amp Williams, 1999). In addition, marriage serves regulative functions that promote conformity to social norms, more conventional lifestyles, and lower levels of deviance of all sorts (Umberson, 1987 Horwitz &amp White, 1998). Moreover, because cohabitation has some, but not all, of the characteristics of marriage, it also has some, but not all, of the mental health benefits (Ross, 1995). Overall, people with more frequent contacts with family, friends, and neighbors report less distress (Lin, Ye, &amp Ensel, 1999). Likewise, people who are involved with...

One of the most difficult tasks facing services researchers is understanding the relative overrepresentation among inpatients of individuals who are African-American or Native American. While the admission rate might be partly explained by socioeconomic factors, the predominance of diagnoses of schizophrenia rather than bipolar disorder among African-Americans has raised questions about possible bias in the diagnostic practices for different groups. At the same time, minority groups such as African-Americans or Native Americans are underrepresented in many outpatient settings, especially when patients with Medicaid are excluded, and have low rates of services use (Snowden and Cheung, 1990 Surgeon General, 1999 Snowden and Thomas, 2000 Novins DK et al., 2000).

The more significant question raised by the acceptance and reliance of the legal system on DSM is whether DSM diagnoses provide an adequate understanding of psychological states for forensic purposes. Legal determinations, whether civil or criminal, typically revolve around issues of impairment. A DSM diagnostic category is not directly relevant to such determinations. For example, in criminal matters, defendants acquitted through a not guilty by reason of insanity verdict are typically evaluated on the basis of their ability to distinguish right from wrong or to resist their impulses. These verdicts are not rendered simply on the basis of whether defendants meet DSM criteria for certain diagnoses such as schizophrenia or bipolar disorder. Nor will specific diagnoses qualify a defendant for a not-guilty-by-reason-of-insanity verdict when others will not. In personal injury litigation, functional impairment is the critical issue for determining damages (Simon 2002). The legal question

Treatment should follow a careful assessment of symptoms and course, a review of general health status, a formal diagnosis, and in some cases physical examination and laboratory testing (Depression Guideline Panel, 1993). This can usually be accomplished in one visit, especially if medically relevant history and past psychiatric and substance abuse history are available. Once a diagnosis of major depression or bipolar disorder has been made, medication treatment is usually indicated. Medication treatment should be initiated with the understanding that the choice of agent may be significantly affected by presenting symptoms and concurrent psychiatric, medical, or substance abuse diagnoses. Concomitant supportive, educational, and or cognitive psychotherapy is usually indicated, although in severe depression or mania significant modifications in the methodology and goals of psychotherapy are usually required, and these will change over time depending on the extent and rate of clinical...

Lifetime prevalence rates of psychiatric comorbidity with bipolar disorder are 42 to 50 .16 Comorbidities, especially substance abuse, make establishing a definitive diagnosis more difficult and complicate treatment. Comorbidities also place the patient at risk for a poorer outcome, high rates of suicidality, and onset of depression. Psychiatric comorbidities include

In comparison to the data available for the use of antidepressant drugs, research with antimanic drugs is more limited. In part this is because alternatives to lithium and antipsychotics have only recently become widely available and in part because clinical research involving people afflicted with bipolar disorder is inherently difficult, especially long-term studies. While there is general agreement that the monoamine systems are involved in antidepressant responses, the neural systems involved in the mechanism of antimanic drugs are poorly defined. TABLE 8.7. Treatment Recommendations for Patients with Bipolar Disorder by the American Psychiatric Association (2002) A comprehensive review of the diagnosis and treatment of bipolar disorder has recently been published by the American Psychiatric Association (2002). Treatment recommendations are listed in Table 8.7.

While only approved by the FDA for the treatment of drug-resistant schizophrenia, the atypical antipsychotic drug clozapine has been shown to be effective in the treatment of mania and dysphoric mania (McElroy et al., 1991 Alphs and Campbell, 2002). Eighty-six percent of 14 bipolar patients with psychotic features showed significant improvement, and 7 of these patients were followed for an additional 3- to 5-year period with no further hospitalizations (Suppes et al., 1992). Other studies suggest clozapine is also effective in maintenance treatment of patients with bipolar disorder (Alphs and Campbell, 2002). Because of the risk of potentially fatal agranulocytosis, clozapine should not be used unless other first-line agents or traditional antipsychotic drugs have failed. antipsychotics. Olanzepine, risperidone, and quetiapine are all being studied as both monotherapy and as an adjunctive therapy for treatment of acute mania. Of the three, olanzapine is the best studied, with...

The general test of contractual capacity is to determine whether the subject has the ability at the time of signing the contract to understand the nature of the transaction, its scope and effect, and its nature and consequences. In some jurisdictions, if a person is under guardianship as a result of the inability to care for himself or herself, he or she may be forbidden from entering into contracts, and any that are signed are void. In other jurisdictions and other circumstances, when a person was not already adjudicated by the court but was equally incompetent to enter into the binding contract, the contract may be voidable. Contracts entered into by minors and intoxicated persons are also voidable. Persons with bipolar disorder are often extravagant in contracting to do things consistent with their grandiose delusions. When they recover, actions to void the contracts may result. These can be difficult cases because the person's manic actions are based on grandiose optimism and,...

The migration of neurons from the ventricular zone to their proper positioning in the cortex is well orchestrated and requires a multitude of neural events including start signals, cell-cell recognition, cell adhesion, motility, and stop signals. Since schizophrenia appears to involve disturbances in cortical migration, researchers have focused their attention on some of the molecules thought to play a role in this process. One such candidate is a protein called reelin. Reelin is thought to help guide newly arriving migrating neurons to their proper destination, though the precise mechanism is presently unknown. A recent study (Impagnatiello et al., 1998) revealed that patients with schizophrenia only have about half of the normal levels of reelin and its transcript in all of the brain areas examined (prefrontal and temporal cortex, hippocampus, caudate nucleus, and cerebellum). Interestingly, while reelin levels are normal in patients with other psychiatric disorders such as unipolar...

Lines, research on everyday creativity and bipolar affective disorders indicates that higher creativity appears in connection with somewhat milder forms of bipolar disorders - as dealt with further below. This may yet be in the service of health, not appearing in the most severely ill. The pattern appears despite subjects' areas of endeavor. There is higher familial creativity in many cases, but it does not 'run true' to a particular modality or interest, such as the Bach family of musicians. Hence the creative impulse might emerge for one person in art, one in schoolteaching, and one in business.

One can make some general statements. Consider the simpler genetic model of sickle cell anemia, where a genetically homozygous person with the full-blown syndrome may suffer and die young, but where the heterozygote may have a mild anemia at best, but still manifest the compensatory advantage Resistance to malaria. Everyday creativity has been suggested as a compensatory advantage for certain better-functioning individuals at risk for bipolar disorders, and for some mild schizophrenia spectrum conditions as well. Some potential generalizations 'Creative benefit' fits an inverted-U pattern of Compensatory Advantage. Evidence supports higher everyday creativity in the presence versus absence of risk for bipolar disorders. Yet, contrary to the stereotype, it is not the sicker people who benefit most. Higher creativity is found in better functioning individuals (e.g., cyclothymes not manic-depressives), or people in better functioning mood states (mild mood elevation especially, and not...

Certain results are relevant to creativity as compensatory advantage, as reported above, for persons at risk for bipolar disorder showing creativity with mild mood elevation. In addition, Isen and colleagues have shown a mild positive mood appears to augments creative thinking. In general. Here, participants solving Mednick Remote Associates tasks in a positive mood state both solved (a) more problems than controls, and (b) more using an insight versus analytic strategy.

The relationship between psychotic bipolar disorder and schizophrenia is unclear, but certainly within schizophrenia, full-fledged manic syndromes occur and serious depressive episodes are common. These can occur either during psychotic episodes or when psychotic symptoms are either absent or stable. The lifetime risk for major depression is very high, with perhaps a third to a half of patients experiencing at least one such episode. This problem contributes to the very high risk of suicide in schizophrenia approximately 10 percent of patients may kill themselves.

Although patients with even very severe mental disorders can often work in a limited capacity or in a sheltered setting, certain disorders clearly are more likely to result in work impairment. Psychotic conditions such as schizophrenia or severe bipolar disorder routinely lead to major impairment in social and occupational functioning. Similarly, certain chronic anxiety and depressive disorders that are unresponsive to treatment can be disabling, if not from all work, then perhaps for the type of work that the patient was for

The DSM-IV-TR (APA, 2000) diagnoses affective disorders following brain injury primarily by their associated syndromic presentation (i.e., major depression, dysthy-mia, or bipolar disorder) or as a consequence of their association with a particular medical illness (i.e., secondary to the organic disorder such as 293.83 Mood Disorder Due to a General Medical Condition) with the predominant symptom type indicated by subtypes, such as with depressive features, with major depressive-like episode, with manic features or with mixed features. The general medical condition is specified by an Axis III diagnosis (e.g., 850.9 Concussion or 851.80 Contusion, cerebral). The differential diagnosis of this condition could include the following conditions adjustment disorder with depressed mood, emotional lability, apathy and posttraumatic stress disorder (Robinson &amp Jorge, 1994, 2005). As was the case with the depressive states, mania subsequent to TBI has been variously described as secondary...

Tiousness and public sensitivity to the issue. Behavior geneticists such as Robert Plomin at Pennsylvania State University and Joel Gelernter at Yale University argue that the field has been misrepresented. They point out that many human behavioral genes, or at least chromosomal or molecular markers thought to be associated with specific genes, have been correlated with specific behavioral types such as Tourette's syndrome (leading to uncontrollable movements and speaking), schizophrenia, manic depression, alcoholism, attention deficit hyperactivity disorder (ADHD), and homosexuality, to name just a few. These correlations suggest strongly that there might be a significant genetic component to these behaviors. Human behavior genetic researchers emphasize that they do not discount the role of environment, nor the additive effect of many genes impinging on any given behavior. In fact, they make a point of emphasizing that the outcome of any behavioral development in humans (or any other...

Abnormalities in brain structure and function have been consistently observed in patients with affective disorders and computed tomography (CT) scanning of these patients has revealed ventricular enlargement in bipolar disorders, unipolar depression, and mixed affective disorders (Post, 2000). Numerous studies have shown that elderly depressed individuals possess values more similar to those with irreversible dementia than to normals (Post, 2000). The best replicated finding across various depressed populations (young versus old, drug-naive and medication refractory disease and in patient subgroups) is a decrease in frontal lobe activity during restingstate functional imaging studies (Post, 2000). The changes involve the dorsolateral

Early studies of treatment samples diagnosed with less systematic criteria concluded that the prevalence of schizophrenia was equal in males and females (Dohrenwend et al., 1980). It is instructive that the lifetime prevalence rate for schizophrenia in the Israeli community cohort was twice as high in men (10.2 per thousand) compared to women (5.3 per thousand) (Dohrenwend et al., 1992). This cohort was not biased by treatment seeking or chronicity (Angermeyer et al., 1989 Munk-Jorgensen, 1985), and the diagnosis was based on a modern classification system. Recent findings based on incidence data indicate a male excess in first-episode schizophrenia (e.g., Murray and van Os, 1998), especially in populations with onset under age 35 (Beiser and Iacono, 1990 Jablensky, 1986 Jones et al., 1998 Riecher et al., 1991). In the Suffolk County sample, where consensus-based DSM-IV diagnoses were applied, the male female ratios were 3 1 for schizophrenia, 1 1 for bipolar disorder...

There have been very few first-admission follow-up studies of patients with affective psychosis, and those that exist are primarily studies of patients in academic medical centers. Coryell et al. (1990a, b) published two parallel studies on psychotic depression and psychotic bipolar disorder, finding similar predictors of poorer outcome as is seen in schizophrenia, namely, poorer adolescent social functioning and longer duration of index episode. For bipolar disorder, both Coryell et al. (1990b) and Tohen et al. (1992) reported that the presence of mood-incongruent delusions also predicted poorer outcome. More recently, Strakowski et al. (1998) assessed the 12-month course of first-admission patients with affective psychosis and found that the sample had great difficulty recovering from their illness, and that delayed recovery was significantly predicted by low socioeconomic status, poor premorbid functioning, treatment noncompliance, and substance abuse.

More recent work has also looked specifically at mood disorders and noted apparently genetically mediated connections of these affective disorders with creativity, socioeconomic, status and achievement. This entry focuses on the affective disorders, which are mental health disorders characterized by unusual and troublesome variations in mood that interfere with a person's functioning. In the DSM-IV-TR (the current edition of the psychiatric diagnostic manual), the relevant categories are termed mood disorders. Although there is currently a great deal of interest and controversy involving the diagnosis and treatment of bipolar disorder in children, this entry refers only to disorders of adults.

Next are the bipolar disorders, bipolar disorder type I and bipolar disorder type II, as well as cyclothymic disorder. Bipolar I disorder is diagnosed if someone has had at least one lifetime manic or mixed episode, and often the person will have had major depressive episodes as well. Bipolar I disorder can come with a most recent episode of manic, hypomanic, depressed, or mixed. In contrast, individuals with bipolar II disorder have had one or more major depressive episodes, have never had a full-blown manic (or mixed) episode in their lifetimes, but have experienced at least one of the more moderate hypomanic episodes. Cyclothymic disorder is characterized by more mild alternations in mood, with numerous periods of hypomanic and depressive symptoms. Bipolar disorders I and II, and major depressive disorder, can also have psychotic features.

A dynamically changing system that contains nonlinearities is also capable of chaotic behavior, something artist, psychologist, and theorist Tobi Zaussner and others have suggested as an attribute of both creativity and well-lived life. Notably, the experiences of bipolar disorder also change with time and have specific phases, and some authors believe that the disorder includes chaotic variations in mood, although this assertion is currently controversial.

A number of potent and effective pharmacological treatments are available for the mood disorders, as well as empirically-supported psychotherapeutic treatments, notably cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) for depression. For depressive disorders a combination of medication and psychotherapy is likely to have the best results, although many people use one or the other. For bipolar disorders psychological treatment is often combined with or secondary to medication management if the client is willing to utilize pharmacotherapy. A variety of empirically supported psychological treatments are available for the bipolar disorders, including psychoeducational interventions to enhance medication compliance, CBT, marital and family therapy (including Miklowitz and colleagues' family focused treatment), as well as interpersonal and social rhythm therapy. Some productive and creative individuals suffering from mood disorders may be reluctant to engage in...

The epidemiologic data on rates of bipolar disorder is most notable for its similarities across cultures rather than differences. Rates of bipolar disorder are similar in men and women, but higher in divorced individuals when compared to married persons. Rates of bipolar disorder are substantially lower than for unipolar major depression.

In the last two decades, a number of population-based studies were conducted that have estimated the lifetime prevalence of bipolar disorder to be approximately 1 (see Table 1). In 1978, Weissman and Myers published the first epidemiologic survey using research diagnostic criteria. The authors utilized the Schedule for Affective Disorders and Schizophrenia and the Diagnostic Research Criteria (SADS-RDC) (Spitzer et al., 1978). Weissman and Myers sampled 1,095 households and identified a lifetime prevalence rate of 0.8 for mania and 0.8 for hypomania. They found that bipolar disorders cluster in the higher socioeconomic classes, with 4.6 in Hollingshead and Redlichs classes 1 and 2 (1958), 1 in class 3, 0.9 in class 4, and no cases in class 5. TABLE 1. Lifetime Prevalence of Bipolar Disorder across Different Countries TABLE 1. Lifetime Prevalence of Bipolar Disorder across Different Countries

In this chapter, we only review the findings related to bipolar disorder. The ECA program collected data on bipolar disorder according to the DSM-III criteria with the use of the Diagnostic Interview Schedule (DIS) (Robins et al., 1981). With the exception of the study conducted by Weissman and Myers (1978), it was the first study in the United States that obtained prevalence rates for bipolar disorder utilizing structured diagnostic instruments. Using a probability sample, the ECA project obtained prevalence data for Bipolar I and Bipolar II disorders, but did not obtain information on cyclothymic disorder. In addition to obtaining prevalence rates of Bipolar I and II disorders, an estimate of specific manic symptoms was also obtained (Weissman et al., 1991). The criteria for a manic episode consisting of elevated, expansive, or irritable mood for at least 1 week duration had a lifetime prevalence of 2.7 . The most frequent manic symptom reported was hyperactivity (9.3 ), followed by...

In a more recent clinical reappraisal study, Kessler and collaborators (1997) reported that the only manic symptoms that could be assessed with validity were euphoria, grandiosity and decreased need to sleep. The lifetime prevalence of bipolar disorder estimated considering the validated symptom profile was 0.4 . This study was conducted by reinterviews conducted by trained clinical interviewers and final diagnoses determined using a best estimate approach. The correspondence of the initial NCS diagnoses and the clinical reinterviews was low with a high degree of false-positive cases diagnosed in the initial NCS assessment. The investigators concluded that the true lifetime prevalence of bipolar disorder was not as high as the originally reported value of 1.6 , but it also was not as low as determined by the narrow definition of the clinical reappraisal. They estimated that the lifetime prevalence of bipolar disorder is approximately 0.9 . Of note, all cases were found to have at...

In addition to the ECA study, a number of population-based prevalence studies using structured diagnostic instruments and modern diagnostic criteria have recently been conducted outside the United States that have included the assessment of individuals with bipolar disorder. A study conducted in the Netherlands (Hodiamont et al., 1987) utilized the Present State Examination (PSE) instrument, which uses the International Classification of the Diseases (ICD) system. For manic episodes, the prevalence was 0.1 for both genders.Levav et al. (1993) conducted a prevalence study in Israel in a population defined as a ten-year cohort born between 1949 and 1958. Cases were defined using the clinician-administered SADS instrument and reported relatively low rates. The 6-month prevalence rate for manic episode was 0.1 . In contrast, Szadoczky et al. (1998) in a study conducted in Hungary found a lifetime prevalence rate of 2.4 of bipolar disorder. The Netherlands Mental Health Survey and...

More than one in five American children suffers from a diagnosable mental disorder. Drawing upon U.S. Surgeon General estimates, 13 percent of persons younger than 18 have one of nearly a dozen anxiety disorders, 10 percent have conduct disorders, 6 percent have mood disorders, and 3 percent have severe mood and thought disorders, such as bipolar disorder, schizophrenia, and autism.

The ECA study (Weissman et al., 1991) reported that individuals suffering from bipolar disorder are high users of health services 38.5 will receive outpatient psychiatric treatment within a one-year period, and 9.6 will receive inpatient treatment within a six-month period. Approximately 79.2 received treatment in a medical outpatient facility, and 29.5 received treatment in a medical inpatient facility (six-month period). Regier et al. (1993) described the de facto U.S. mental and addictive disorders service system as composed by general medical physicians, other human services professions, and the voluntary support sector the latter includes self-support groups, family and friends. For bipolar disorder, 60.9 received one of those services with overlap among sectors. Professional services were received by 58.9 of Bipolar (I and II) patients. Specialty mental health was provided by general medical (32.4 ) and other human service (10 ) professionals. The voluntary support network...

A large amount of attention has been directed to the affective disorders of creative persons. Typically these are bipolar disorders, which are characterized by mood swings. Such mood swings may be functionally tied to creative work and here again it is possible to speculate that there are relevant changes of perspective. Put briefly, the mood swing may provide the individual with more than one perspective of his or her own work.

The origins of the idea that mania might be a distinct clinical entity within mental illness has been attributed to the French clinicians, Falret (1854) and Baillarg, (1854 see reviews by Krauthammer and Klerman, 1979 Roth, 2001). However, it was Kraepelin (translation 1921) who developed the notion that manic-depressive insanity is different from dementia praecox, the latter called schizophrenia by others. Kraepelin considered that the predominance of affective features, the periodic course and ultimate good prognosis were sufficient to differentiate it from dementia praecox in terms of cross-sectional phenomenology and long-term course. Although his ideas on schizophrenia were relatively specific, identifying subjects that would be familiar today as having severe schizophrenia, Kraepelin's category of manic-depressive insanity included all forms of serious and recurrent affective illness, though he believed there was a common and fundamental core. Concepts of manic-depression have...

Weller et al. (1986) searched the literature of case reports describing children with severe psychiatric symptoms and identified 19 cases (12 ) out of 157 with a diagnosis of mania in the original report. They rediagnosed another 12 of cases previously diagnosed as psychotic or schizophrenic as having DSM-III mania. In a retrospective study by Loranger and Levine (1978), 0.5 of adult patients with an established diagnosis of bipolar disorder reported an age of onset between 5 and 9 years and 7.5 between the ages of 10 and 14 years.

Der and Bebbington (1987) reported a similar high rate of mania and hypoma-nia in both sexes of those born in the Caribbean, whereas Irish males were found to have a low rate. The increased incidence of affective disorder in those of Caribbean origin may be explained by a propensity of individuals who are predisposed to bipolar disorder being more likely to migrate, an unlikely explanation similar to that proposed in schizophrenia and with as little empirical support (Bogers et al., 2000). However, it could also be a result of social or environmental factors related to urban living. Both acute and chronic social adversity may operate across first and second generation, African-Caribbean populations. Some components (e.g., limited opportunity) may be intensified in the British-born, second generation, where they may act as precipitating factors. Thus, we consider it vital to disentangle the differences between concepts of race, ethnicity, migration, and socioeconomic status, all of...

Treatment options for bipolar disorder in HIVpositive youth include divalproex sodium when neutropenia is not a concern, other mood stabilizers such as lamotrigine, and, rarely, lithium (Kowatch and Delbello 2006). Similarly, drug-drug interactions, neutropenia, and hepatotoxicity are clinical management concerns.

Prior to the 1950s, most studies that examined the utilization of services for persons with mental health problems used samples of persons who were already in treatment. Two early studies that were immensely influential illustrate the nature of this research. In a study in Chicago conducted in the early 1930s, Faris and Dunham (1960) undertook a complete census of patients receiving care in public and private mental hospitals and examined the correlation between treatment rates and patients' area of residence. They concluded that schizophrenia was associated with living in socially disorganized areas, although they failed to find such a pattern for bipolar disorder.

While the estimates of treatment rates vary among surveys due to differences in the populations studied, time periods, and measurements of disorder and types of services used, all of these studies indicate that the majority of adults in the community with mental health problems do not receive treatment. One possible explanation of these findings is that definitions of need based simply on meeting diagnostic criteria are too broad and capture a large number of persons who do not need treatment (Mechanic, 2003). Of greatest concern are the low rates of treatment for persons with the most severe and disabling disorders. McAlpine and Mechanic (2000) estimated that approximately three-fifths of those in the community who meet the criteria for serious mental illness (e.g., schizophrenia or bipolar disorder) did not receive specialty mental health treatment in the year prior to interview. Even when need for treatment is more conservatively defined as disorders associated with the greatest...

There is an increased risk for depression and anxiety in children with epilepsy. Depression and anxiety disorders have been identified in these patients prior to the start of treatment, and studies with sibling control subjects found higher rates of mood disorders early after diagnosis and the initiation of treatment. This raises the possibility that the psychiatric and seizure presentations have a common neurophysiologi-cal etiology (Austin et al. 2001). There are also associations between mood disorder, disruptive behavior, and suicidal ideation in these patients (Caplan et al. 2004). The relative risk for suicidal behavior in these patients is not related to psychosocial stress or medication side effects. These patients are at greater risk for suicide than the general population (Plioplys 2003). Generally, older female patients with lower IQ, neurological disabilities, and comorbid learning disorders are more likely to experience depression along with a seizure disorder (Buelow et...

1954), mainstream analysts have come to terms with the limitations of the analytic method for these disorders, and analyzability guidelines typically recommend excluding patients with serious psychiatric illnesses (Weinshel, 1990). Nonetheless, patients with severe mental illnesses treated with intensive psychoanalytic psychotherapy did derive significant improvement (Wallerstein, 1986) even if they did not meet the usual analyzability criteria or achieve the usual goals of psychoanalysis. For example, some of these patients would today meet criteria for schizoaffective disorder (a mixture of mood and psychotic symptoms), obsessive-compulsive disorder, and manic depression, all diagnoses now treated primarily with medications.

The second strand of creativity-affect research deals with subjective states. Here attention has focused mainly on the valence of states, but the association between creativity and positively or negatively valenced states remains inconclusive. On the one hand, some correlational studies, experimental studies (using affect-induction methods), and meta-analyses suggest that positive affect enhances creativity. This is supported by research on bipolar disorder reporting that positively valenced states (moderate 'mood' elevation) are associated with creative performance. On the other hand, some studies find positively valenced states inhibiting creativity, and negative states facilitating it. A possible mechanism for this is that negatively valenced states enhance creativity through increased task persistence and perseverance, whilst positive states promote satisfaction and reduce motivation to seek better quality outputs (for further discussion on this suggestion see the next section).

A nonlinear relationship has been found between creativity and stress in some studies. Specifically, divergent thinking performance (on verbal tasks) seems to be lower in individuals in conditions of high stress and low stress than in participants in moderate conditions, in an inverted 'U' shaped relationship (corresponding to the classic Yerkes-Dodson law relating arousal and general task performance). Similarly, fluency has shown to be highest in individuals in a condition of moderate stress activation. Research on bipolar disorder and its relationship with creativity has shown that the elevation of mood that comes with the disorder may enhance creative behavior. In sum, moderate levels of stress may provide the arousal needed for creative tasks without diminishing cognitive resources.

Antonio Preti and Paola Miotto studied over 3000 internationally eminent persons in the visual and literary arts such as writers, poets, playwrights, painters, sculptors, and architects and found 59 suicides in that group. The prevalence of suicide was particularly high among poets and writers, and in female artists (a rate of 4.3 compared to 1.75 among male artists). Female poets were at the highest risk six out of 42 female poets included in the sample died from suicide. Self-destructive behavior in this group of eminent artists was not limited to suicide there were several deaths directly related to alcohol abuse, for example, Dylan Tomas and Edgar Alan Poe.

Although it has been found in the United States that the imitation effect holds for entertainers (such as actors and television stars) and political celebrities, this effect has not been reported for other categories of celebrities, including artists and the economic elite. It is possible that the number of people who can strongly identify with elite artists and imitate their self-destructive behavior is too small to have a significant impact on rates of suicide. The exception may be stars of popular music and writers who have gained a wide fame and recognition, such as Ernest Hemingway. It is of interest to note that the suicide of Kurt Cobain, the lead singer-guitarist and lyricist of the grunge group Nirvana in April 1994 did not lead to an epidemic of suicides among his fans despite his worldwide fame and the excessive media coverage of his death. A few cases of imitative suicide were found in the United States and Australia immediately after Cobain's death and an...

Patients in an acute crisis or with disaster-related trauma may or may not require treatment. Crisis treatment is often necessary if the patient is suicidal or at risk for violence, has an acute medical emergency, or has a major psychiatric disorder (psychosis, PTSD, bipolar disorder, depression, overwhelming anxiety). All treatment is best when it is offered voluntarily or upon patient request.

The primary treatment for borderline personality disorder is psychotherapy complemented by symptom-targeted pharmacotherapy. Certain types of psychotherapy and medications are effective in the treatment of borderline patients. Most will need extended psychotherapy to attain and maintain lasting improvement in their personality, interpersonal problems, and overall functioning. Pharmacotherapy often has an important adjunctive role, especially for diminution of symptoms such as affective instability, impulsivity, psychotic-like symptoms, and self-destructive behavior (APA, 2001 Soloff, 2008).

Mood disorders are divided into depressive disorders, bipolar disorders, and disorders based on etiology (i.e., mood disorders caused by general medical conditions and substance-induced mood disorders). For primary care physicians, identification, treatment, and management of depressive disorders are essential. Bipolar disorders, which are typically more complex to identify and treat, are best referred to mental health professionals for ongoing treatment. Therefore, this chapter concentrates on identifying bipolar disorder and distinguishing between unipolar and bipolar depression, but does not delve into the specifics of treating bipolar patients. Bipolar disorder is a chronic mood disorder characterized by the presence of mania (bipolar I disorder) or hypomania and depression (bipolar II disorder). Manic episodes are distinct periods of abnormally and persistent moods that can be euphoric, expansive, or irritable. Although manic patients are often thought to be always euphoric, only...

Patients who experience refractory depression or psychotic depression are best treated by specialty providers. Patients with bipolar disorder should be referred as well, especially those suffering from bipolar depressions, as they are often especially difficult to treat, usually require complex polypharmacy, and worsen with inappropriate treatment. Patients requesting or needing psychotherapy or behavioral therapy may be referred to a mental health provider.

Psychotropic medications are selected to address target symptoms that cause significant subjective distress or functional impairment (Green 2007). Target symptoms are often specific dimensions of a psychiatric diagnosis (e.g., sad mood as a symptom of depression). Target symptoms may also be a common shared dimension of multiple psychiatric disorders. For example, sleep disturbance can be a symptom common to depressive disorders, bipolar disorder, delirium, substance abuse, adjustment disorders, or sleep disorders. Target symptoms may also be present when full categorical criteria for a

Much less work has documented average age of onset of manic episodes and Bipolar disorders. According to retrospective studies, 20 to 40 of adults with bipolar disorder report that onset occurred during childhood (see Geller and Luby, 1997). A study of first admissions for bipolar depression in the United Kingdom revealed a dramatic increase in onset of bipolar among males and females after age 15 (Sibisi, 1990). Familial and Genetic Risk. Despite the abundance of well-controlled family and genetic studies that have employed sophisticated methodology to investigate the transmission of affective disorders among adults, there are only a limited number of controlled family studies that have focused on the manifestation of affective disorders among adolescents. The results of family, twin, and adoption studies of mood disorders of adults have demonstrated conclusively that genetic factors are involved in the susceptibility to mood disorders, particularly bipolar disorder (Merikangas and...

In Ayoub's (2006) study of 30 children with MBP, 23 had gastrointestinal symptoms including vomiting, failure to thrive or grow, reflux, esophagi-tis, chronic secretory diarrhea, neurological intestinal pseudo-obstruction, and chronic abdominal pain 30 were reported to have recurrent seizures 20 had repeated episodes of apnea 13 experienced abnormal serum insulin levels either as uncontrolled diabetes or as unexplained hypoglyce-mia 10 were diagnosed with rare autoimmune or genetic disorders and 10 had unexplained exacerbations of asthma (Ayoub 2006). In addition, 7 were poisoned and had feigned bleeding difficulties. A final group of children in Ayoub's (2006) prospective study had psychiatric or learning disabilities that were exaggerated, fabricated, or induced ( 10 ) their problems included ADHD, bipolar disorder, and psychosis.

Before its widespread use, and given the initial high cost of the implant and surgical procedure, efforts are underway to document whether VNS is both efficacious and cost effective in the long term for patients with depression. Other VNS open trials are underway in anxiety disorders (PTSD, panic disorder, and OCD), in the early stages of Alzheimer disease, rapid cycling bipolar disorder, and migraine headaches. In a related venue, subdiaphragmatic bilateral VNS is being tested in morbid obesity as it may modulate satiety signals.

Some of the most intriguing questions are derived from research about how treatment processes differ by race and ethnicity. A growing body of research has suggested that clinical decisions about diagnosis and treatment vary by the race or ethnicity of the patient independent of illness characteristics. Neighbors and colleagues (2003) reported that symptoms are identified based on patients' race or ethnicity. Black patients were more likely to receive a diagnosis of schizophrenia while white patients were more likely to be diagnosed with bipolar disorder. Treatment regimens also differ by race and ethnicity. Walkup and colleagues (2000) found that controlling for illness characteristics, African Americans with a diagnosis of schizophrenia were more likely than Whites to receive antipsychotic medication dosages higher than the recommended ranges. As yet, we cannot fully explain these and other similar findings, but social control theory offers some possible avenues for further research.

Propose that as the association between the injury and the psychosis is a temporal one, it should include all forms of psychotic disorder. While the term psychosis is often equated with the diagnosis of schizophrenia, it is more accurately viewed as a nonspecific presentation of many conditions including depression, bipolar disorders, delirium, and dementia amongst other conditions (McAllister &amp Ferrell, 2002).

Clinical Manifestations and Associated Disorders.Tics are defined as simple or complex repetitive movements that occur out of background of normal motor activity. They are usually fast (myoclonic) but can be slow (dystonic). They increase with fatigue and after stress and decrease with concentration. y GTS is characterized by chronic waxing and waning motor and vocal tics, usually beginning between the ages of 2 and 21 years. It affects boys more frequently than girls. About half the patients start with simple motor tics, such as frequent eye blinking, facial grimacing, head jerking, or shoulder shrugging, or with simple vocal tics such as throat clearing, sniffing, grunting, snorting, hissing, barking, or other noises. Complex motor tics include squatting, hopping, skipping, hand shaking, and ritualized movements such as compulsive touching of objects, people, or self. Complex vocal tics include semantically meaningful utterances, including shouting of obscenities and profanities...

Evidence regarding treatment of bipolar disorder in children and adolescents is more limited than in adults. Children and adolescents appear to be particularly sensitive to medication side effects. With these caveats, an increasing body of evidence supports the use of mood stabilizing drugs and atypical antipsychotic drugs in children and adolescents with bipolar disorder. Lithium is FDA approved for treatment of bipolar disorder in children and adolescents as young as age 12. Aripiprazole and risperidone are FDA approved in children and adolescents as young as age 10. The guidelines additionally support DVP, carbamazepine, olanzapine, quetiapine, and risperidone.49 Comorbid conditions must be addressed in order to maximize desired outcomes. For comorbid bipolar disorder and attention deficit hyperactivity disorder when stimulant therapy is indicated, treatment of mania is recommended before starting the stimulant in order to avoid exacerbation of mood symptoms by the stimulant....

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Understanding And Treating Bipolar Disorders

Are You Extremely Happy One Moment and Extremely Sad The Next? Are You On Top Of The World Today And Suddenly Down In The Doldrums Tomorrow? Is Bipolar Disorder Really Making Your Life Miserable? Do You Want To Live Normally Once Again? Finally! Discover Some Highly Effective Tips To Get Rid Of Bipolar Disorder And Stay Happy And Excited Always! Dont Let Bipolar Disorder Ruin Your Life Anymore!